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Home My Public Portal About9246 KEY WEST ST_Miscellaneous__ of,_Cu �y ,WORKERS'COMPENSATION DECLARATION CE 875(11-84) M I SC E L LA N EO U S APPLICATION CE 875 f� I herhy affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION `,lull insure; o, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS Certified copy is hereby furnished BUILDING Z G ADDRESS LOCALITY Certified copy is filed with the county building inspection LOCALITY n NEAREST department L/ CROSS sT Date Applicant NEARESTDISTRI T N GFFF�q(��QQQQpJ UP TYPE PROCE ED BY CROSS ST to I\ , CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v COMPENSATION INSURANCE DESCRIPTION LOT NO tJ cJ BLOCK MAP HIGHWAY IX 4 _ NO NO (CIRCLE) STATE MAJOR SEGO LOCAL B (This section need not be completed if the work involved TRACT NOWOF LDGS ON LOT UT ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) FSM E OF L_ 'PJ►J SIZE OF LOT X , usEXISTING BLDG -t C0 'f 7- I certify that in the performance of the work for which this 4 CD permit is issued, I shall not employ any person in any manner OWNERy _ so as to become subject to the Workers' Compensation Laws ml�lJ OCCUPANCY GROUP � MAIL p / 1 O Date Applicant ADDRESS w NOTICE TO APPLICANT If, after making this Certificate of CITY TEL 2 -�S OCCUPANT LOAD a Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPL CATION FOR EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked ❑ ❑ No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO OF EXITS ness and Professions Code, and my license is in full force and effect or F -Room-t PARKING SPACES REQ'D PROVIDED - RDoM License Number Lie Class LIMITED TIME USE Contractor Date JiC]lJ N�iD , DATE DATE ElI am exempt from the licensing requirements as I am a �U FROM TO licensed architect or a registered professional engineer SIZE OF NO OF 1 s R'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG `�S STORIES # • ys r3'ly RE mess and Professions Code) FINAL APPROVAL ° 5lg LIC or Reg No Date PRESENT USE OF BUILDING `/.70/ HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS 0 ) a2 5 �,8 8 ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING I, as owner of the property, will do the work and the SPACES PROVIDED 2Ekff.D PW S structure is not intended or offered for sale (Section �� 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency L-tv G Q To for the performance of the work for which this permit is issued(Sec 3097,Civ C) Lender's Name PROPOSED MAX OCC Lender's Address - I certify that I have read this application and state that the PERMIT FEE - above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon e above-mentioned property for inspection purposes .__ J'�Q SEE REVERSE FOR EXPLANATORY LANGUAGE T e��7 ignature of Pe mittee Date